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UNITED STATES NAVY 



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Rear Admiral Bartholomew W. Hogan MC USN 
Captain Leslie B. Marshall MC USN {RET) 


- Surgeon General 
Editor 




Vol. 32 Friday, 24 October 1958 


No. 8 



TABLE OF CONTENTS 



Postnecrotic Cirrhosis 2 

SPECIAL NOTICE 3 

Serum Phospholipids 6 

Cystic Disease of the Breast 8 

Excision of More than Twenty-Five Percent of Body Surface 11 

Cardiac Glycosides in Medical Practice 14 

Postoperative Myocardial Infarction 15 

Cardiac Surgery Associated with Pregnancy . . . 16 

Deck Foot 18 

Voluntary Retirement 19 

Opportunities in Submarine Medicine 19 

Submarine Medicine Technic Training - Applicants Desired . 20 

American Board of Obstetrics and Gynecology 21 

MSC Guest Lecture Series 21 

Dental Officers Memorial 22 

IN MEMORIAM . . 23 

From the Note Book . . 23 

Recent Research Reports 25 

DENTAL SECTION 

Experiences and Problems with Subperiosteal Implants 28 

Dental Corps Exhibit at ADA Meeting in Dallas 29 

RESERVE SECTION 

Correspondence Course Training 29 

AVIATION MEDICINE SECTION 

Naval Aviator - Flight Surgeon 32 

Pros and Cons of Stimulating Drugs 33 

Partial Pres sure Suit Protection 37 



Medical News Letter, Vol. 32, No. 8 



Postnecrotic Cirrhosis 

Characteristically, the lesions of acute viral hepatitis heal without 
scarring, a fortunate circumstance apparently related to the self-limited 
character of the infection, the relatively small size of the individual foci 
of necrosis, and preservation of the supporting reticulum, features which 
permit rapid regeneration and restoration of the normal lobular architec- 
ture. 

However, when the zones of necrosis are large and involve whole lob- 
ules or groups of contiguous lobules, as is known to occur in the more florid 
and usually protracted form of viral hepatitis that produces subacute hepatic 
necrosis (subacute yellow atrophy), there is collapse and ultimate "collagen - 
ization" of the supporting stroma and nodular hyperplasia of the surviving 
parenchyma. This gives rise to a form of cirrhosis in which the liver is 
studded with coarse nodules separated by broad bands of connective tissue. 
Occasionally, when the zones of necrosis bridge small groups of lobules in 
a symmetrical pattern, fine scarring and nodulation result giving the liver 
a granular appearance. During the early stage of subacute hepatic necrosis, 
the liver shows the characteristic histological features of acute viral hepatitis, 
but once extensive scarring and nodulation have occurred, the postnecrotic 
cirrhosis produced cannot be distinguished from that due to other causes, 
such as hepatotoxins, drug reactions, and metabolic disorders like the 
deToni-Fanconi syndrome and Wilson's disease. 

On the basis of autopsy experience, it has been estimated that approx- 
imately 10% of all cases of cirrhosis seen in this country are of the post- 
necrotic variety. In only a small fraction of these can the etiology be estab- 
lished with certainty. However, there is an impression, based largely on 
circumstantial, clinical, and epidemiological evidence, that the hepatitis 
virus may be responsible for a high proportion of such cases. Certainly, 
when the cirrhosis follows closely on the heels of a typical attack of acute 
viral hepatitis with jaundice, there can be little doubt about the etiology. 
However, in most cases, there is no history of antecedent jaundice so that 
if the virus is to be implicated, it must be assumed that it is capable of 
producing subacute hepatic necrosis without jaundice. 

This report draws attention to the clinical and morphological features 
of anicteric infections with the hepatitis virus that give rise to subacute 
hepatic necrosis and postnecrotic cirrhosis. 

The preponderance of middle-aged and elderly women in the group 
studied was striking; all but one of the 9 patients were women over the age 
of 40 years. 

A relatively abrupt onset with nonspecific constitutional and gastro- 
intestinal symptoms was characteristic. Weakness, fatigability, abdominal 
pain, anorexia, indigestion, nausea, and vomiting were the principal com- 
plaints; they occurred in varied combination and sequence in individual cases. 



Medical News Letter, Vol. 32, No. 8 



SPECIAL NOTICE 

TO ALL ADDRESSEES (EXCEPT U. S. Navy and Naval Reserve 
personnel on ACTIVE DUTY and U. S. Navy Ships and Stations ). 

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Medical News Letter, Vol. 32, No. 8 



Medical News Letter, Vol. 32, No. 8 



Only 2 patients noted fever at the onset. With few exceptions, the abdominal 
pain was dull aching in character, intermittent, and localized in the epigas- 
trium, and was often aggravated by the ingestion of food or by physical 
activity. All but 2 patients noted significant weight loss as the disease pro- 
gressed. 

The symptoms were sufficiently troublesome to induce every patient 
in the group to seek medical attention early in the course of the illness. In 
no instance was the presence of hepatocellular disease recognized, testify- 
ing to the nonspecificity of the complaints. However, it is noteworthy that, 
despite the absence of clinically detectable jaundice, 5 patients noted dark 
urine, light stools and/or pruritis, and all 4 patients tested before the 
appearance of overt signs of liver disease exhibited abnormalities of hepato- 
cellular function — features that were either misinterpreted or dismissed as 
insignificant. 

Careful inquiry revealed only two instances of possible exposure to 
infection with the hepatitis virus. One patient had been a combat soldier 
for an extended period in an area in which viral hepatitis was known to be 
prevalent; another had received a large number of transfusions 30 and 163 
days prior to the onset of symptoms. 

Frank signs of liver disease first became apparent from 2 to 18 months 
following the onset of illness. The first sign pointing to involvement of the 
liver was jaundice in 5 patients, hepatomegaly in 3, and ascites in 1 patient. 

Although the onset was anicteric in every instance, jaundice ultimately 
appeared in 8 of the 9 cases following a preicteric phase which varied in 
duration from 3 to 55 months. Once jaundice became evident, it tended to 
persist with only minor fluctuations. 

Dark urine was noted by all patients in whom jaundice developed. In 
addition, there were 6 patients with light stools and 5 with pruritis, features 
that were responsible for many of the diagnostic errors encountered in this 
group. 

The cases presented clearly indicate that anicteric attacks of hepatitis 
are capable of producing subacute hepatic necrosis and postnecrotic cirrhosis. 
The question arises, however, whether the available evidence warrants the 
assumption that the hepatitis virus was the etiological factor in these cases. 
Certainly, unequivocal proof — which at present demands transmission of the 
virus to human volunteers — was not established. However, all the cases 
fulfilled the less rigid clinical, biochemical, and histological criteria usually 
considered acceptable evidence of specific infection so that the etiological 
diagnosis in this group would appear to rest on as firm a basis as it ever 
does in viral hepatitis, except for the rare instances in which the infection 
is transmitted to human volunteers. Under some circumstances, epidemio- 
logical evidence may lend support to the presumptive diagnosis of viral 
hepatitis, but in sporadic cases, the frequency with which a history of 
exposure to infection can be obtained is seldom greater than it was in the 
present series — namely, in 2 of 9 cases. 



Medical News Letter, Vol. 32, No. 8 



Nine cases of subacute hepatic necrosis with, progression to post ne- 
crotic cirrhosis are described, in which the disease appeared to have its 
inception in an attack of anicteric viral hepatitis. In each instance, biopsy 
material was obtained sufficiently early in the course of the disease to 
demonstrate the histological features usually considered diagnostic of the 
infection. 

With one exception, all of the patients were middle-aged or elderly 
women. Characteristically, the onset was relatively abrupt with nonspe- 
cific constitutional and gastrointestinal complaints, but was followed within 
a period of 2 to 18 months by the appearance of frank signs of chronic liver 
disease. Jaundice was a late development in 8 of the 9 cases, becoming 
evident in 3 to 55 months from the onset. Often, it was accompanied by 
dark urine, light stools, pruritis, and hyperphosphatasemia — features 
that frequently were misinterpreted as evidence of extrahepatic biliary 
obstruction. In addition to the hyperphosphatasemia, marked hyperglobu- 
linemia and high levels of thymol turbidity were helpful diagnostic clues. 
The disease tended to run an intermittently progressive course that was 
little affected by dietary measures and bedrest, and terminated fatally in 
5 of the 9 cases. 

Evidence is reviewed to show that females at all ages are peculiarly 
susceptible to the anicteric form of viral hepatitis that produces subacute 
hepatic necrosis and postnecrotic cirrhosis. The suggestion is made that 
such infections which are readily overlooked or misinterpreted may be res- 
ponsible for many instances of otherwise unexplained cirrhosis — particularly 
those of the classic postnecrotic variety that occur in females, (Klatskin, G. , 
Subacute Hepatic Necrosis and Postnecrotic Cirrhosis Due to Anicteric Infec- 
tions with the Hepatitis Virus: Am, J. Med., XXV : 333-357, September 1958) 

****** 

Serum Phospholipids 

There is increasing evidence that atherosclerosis is a problem with 
many facets. Extensive investigative work is being conducted on the role 
of abnormal lipid metabolism as well as carbohydrate and protein metabol- 
ism in atherosclerosis. Factors, such as thrombogenesis, blood coagula- 
tion, fibrinolysis, arterial wall injury, intimal hemorrhage, and others 
are also subjects of intensive study. 

Most investigators, however, are mainly concerned with the part 
played by lipids in the genesis of atherosclerosis. At one time, these 
studies centered around serum cholesterol and cholesterol metabolism. In 
recent years, the interest in this field has been focused on aspects of lipids 
and lipoproteins other than cholesterol. For example, it is believed by some 
that the concentration of triglycerides in the serum may be an important 



Medical News Letter, Vol. 32, No. 8 



factor in atherogenesis. Neutral fat transport and metabolism may be im- 
portant in atherogenesis. The role of the nonesterified fatty acids in lipid 
transport and their possible relationship to carbohydrate metabolism has 
been investigated. In the study of dietary factors related to atherogenesis, 
the effect of saturated versus unsaturated fats is being carefully watched. 

In this connection, the role of serum phospholipid deserves consid- 
eration. Its presence in atheromatous plaques and its synthesis in the 
arterial wall are well established. Elevations or depressions of serum 
cholesterol are usually associated with changes in a similar direction of 
levels of serum phospholipid. 

In contrast to extensive studies on serum cholesterol in relation to 
age, sex, endocrine factors, and such environmental factors as dietary, 
climatic, and occupational influences, relatively little information is avail- 
able concerning corresponding changes of serum phospholipid. 

Therefore, it seemed profitable to investigate systematically the 
levels of serum phospholipid in a normal population sample. The twofold 
purpose of the study was to establish possible relationships between age, 
sex, and serum phospholipid level, and to assess the relative importance 
of genetic versus environmental influences determining serum phospho- 
lipid levels in a healthy population. 

The sample included 1067 normal persons, 516 males and 551 females 
aged 2 to 77. Among these, were 156 families consisting of 156 fathers, 156 
mothers, and 268 children of these parents. The overwhelming majority of 
these persons consumed a mixed American diet of the usual protein, carbo- 
hydrate, and fat content, similar in its composition to that described by 
Epstein et aL for the working population in New York City. 

Only limited information is available concerning the influence of age, 
sex, and environmental and hereditary factors on serum phospholipid levels 
of healthy persons. Almost no information is obtainable on levels in child- 
hood and adolescence or even among adults in significant numbers. Peters 
and Man concluded that there was no effect of age and sex on serum phos- 
pholipid among 108 persons studied. Foldes and Murphy reached the same 
conclusions. Gertler et al. compared average phospholipid levels of normal 
control subjects and patients with coronary artery disease. They concluded 
that the difference between the two groups was significant, but did not eval- 
uate their observation material in regard to age and sex. Epstein et al. 
could not discern a clear-cut trend in phospholipid levels in relation to age 
and sex. Lindholm investigated serum lipids in 102 males and 93 females 
between the ages of 20 and 91. The phospholipid levels increased steadily 
with age in women, whereas in men this increase was seen only until age 50. 

Most investigators have been interested in serum phospholipid levels 
in disease — particularly atherosclerosis, in the relationship of serum phos- 
pholipids to cholesterol and other lipids, in influencing the level under exper- 
imental conditions, and in studies of phospholipid synthesis and turnover. 



Medical News Letter, Vol. 32, No. 8 



Atheromatous plaques were shown to contain about 20% phospholipid. 
The present study indicates that serum phospholipid levels of healthy per- 
sons consuming a mixed diet increase with age in males earlier in life than 
in females. They are similar to the age-sex changes previously described 
for serum cholesterol, but of lesser magnitude. The levels of serum cho- 
lesterol and of serum phospholipid are distributed throughout this population 
as continuous variables. The present data indicate the existence of a gen- 
etic factor determining serum phospholipid levels in healthy people. 

The positive parent-child and sibling -sibling correlations and the 
negative mother-father correlations support- the concept that serum phos- 
pholipid levels are probably genetically determined in the same manner as 
serum cholesterol levels. These data further indicate that the common 
environment shared by a family does not lead to common serum phospholipid 
levels unless blood relationship exists. Thus, such factors as diet cannot 
be the only factor in determining serum lipid levels of healthy persons. 

On the basis of admittedly limited data, the responsible gene or genes 
are probably not sex-linked, (Schaefer, L. E. , Adlersberg, D. , Steinberg, 
A. G. , Ph.D., Serum Phospholipids - Genetic and Environmental Influences : 
Circulation, XVIII : 341-345, September 1958) 

sfc ^ :£ * # $ 

Cystic Disease of the Breast 

This report presents the findings in 484 private female patients with 
cystic disease of the breast, treated from 1933 to 1951, including the clin- 
ical histories, operative findings, pathologic reports, therapy administered, 
and follow-up examinations on 432, or 90%, of the group. This investigation 
was undertaken, not in an attempt to present solutions to the yet unsolved 
problems of cystic disease of the breast, but to report various gross and 
histologic manifestations of the disease observed in this series of patients 
and to evaluate the results of conservative therapeutic measures utilized in 
their treatment. Consideration is also given to certain factors which pre- 
sented themselves that could be of etiologic significance to the disease and 
its possible relation to malignancy. 

It is impossible to determine with any degree of accuracy what per- 
centage of the adult female population is affected with cystic disease of the 
breast because most women have some pain in the breast occasionally; in 
the majority of female breasts the lobules are normally firmer than those 
in surrounding subcutaneous tissue. Also, those patients with microscopic 
cysts escape detection by routine methods of examination. Because clinical 
evidence of cystic disease of the breast occurs more frequently than carci- 
noma, a safe assumption would be that one of every 15 women in the general 
adult population develops clinical evidence of cystic disease of the mammary 
gland in a menstrual lifetime. 



Medical News Letter, Vol. 32, No. 8 



The highest incidence of cystic disease of the breast was observed 
between the ages of 40 and 49 years; 45% of the patients were in this range. 
Fourteen patients, or 3%, were past the age of 70 years, but in all prob- 
ability, these patients either had cystic disease before menopause or had 
received estrogenic therapy not recorded in their histories prior to the 
time a diagnosis of cystic disease was established. 

The highest incidence of cancer of the breast in 452 patients with 
primary carcinoma observed during this period was also between the ages 
of 40 and 49 years. However, the age distribution in carcinoma was higher 
past the age of 49 years than that of cystic disease. 

Twenty-two percent, or 126 patients, were unmarried with no history 
of pregnancy; 10%, or 48 patients, were married with no history of preg- 
nancy. Forty-two percent, or 202 patients, had a history of one or more 
pregnancies. Ninety patients had incomplete histories concerning marital 
status and pregnancy. In 66 patients in whom adenosis was part of the 
cystic disease complex, sterility was frequent. 

Cystic disease of the breast is a nodular condition, frequently painful, 
not associated with bacterial inflammation, fat necrosis, or new growth. 
It frequently presents no symptoms other than a tender lump or thickened 
area which, when discovered by an intelligent patient, often is accompaned 
by anxiety. The pain in most cases is not severe except in younger women 
with adenosis; it may be present only in the premenstrual period and is 
probably associated with increased vascularity of the breasts produced by 
an endocrine stimulus resulting in fibrous tissue and epithelial proliferation. 
Many patients while bathing or dressing accidentally discover a lump or 
thickened area which is more tender on palpation than the remainder of the 
breast. A review of the histories of 167 patients in whom cysts were presen* 
of sufficient size (4 to 15 cm. in diameter) to be treated by aspiration demon- 
strated that it was not unusual for the observing patient to note that the lump 
varied in size from time to time; other patients stated that when a tumor 
developed rapidly, it was very painful due to an increase in tension of the 
contained fluid. 

Cystic disease of the breast occurs more frequently in younger 
patients than carcinoma, and in older patients more frequently than fibro- 
adenoma. When a large cyst is present and superficially located, fluctua- 
tion can be detected; the tumor is movable in the surrounding breast tissue 
and retraction is less likely to be present than observed in carcinoma. On 
the other hand, when there is a deeply located cyst with a thick fibrous wall, 
it may be difficult to differentiate from carcinoma. Fluctuation does not only 
indicate the presence of a cyst; occasionally a lipoma, sarcoma, or soft 
type of carcinoma may produce a soft tender tumor with a smooth surface. 

When there is a segment of thickened breast tissue involved, usually 
small cysts or dilated ducts {1 to 2 cm. in diameter) can be palpated and, 
as a rule, a correct clinical diagnosis can be established before surgical 
excision is performed when this treatment is deemed necessary. 



10 Medical News Letter, Vol. 32, No, 8 



Aspiration therapy for discrete cysts of the breast has been used by 
a number of surgeons with good results; the aspiration should be performed 
only by surgeons qualified to perform a radical mastectomy when carcinoma 
is encountered. Since 1933, the author has treated certain patients with dis- 
crete cysts of the breast by aspiration of the cyst contents with satisfactory 
results; however, this method of therapy is not recommended unless the 
patient agrees to return for follow-up examinations at regular intervals. 
These patients have cooperated well when this modality of therapy was used. 
The patient is informed in the beginning that if any of the following conditions 
develop and persist, the area is to be excised promptly and histologic exam- 
ination will be made of tissue removed: (1) when aspiration produces a 
bloody fluid or if the fluid returns immediately following a second aspiration; 
(2) if the lump in the breast does not completely disappear following aspira- 
tion; or (3) if aspiration does not yield fluid. 

It has been established by Goldberg and associates that approximately 
one of every 20 women in the State of New York develops carcinoma of the 
breast in a lifetime. A careful follow-up of this series of 484 patients with 
cystic disease for a period of 5 to 18 years disclosed that only 4 developed 
carcinoma of the breast. Of 452 patients with primary carcinoma of the 
breast who were treated during the same period, 4 had previously undergone 
surgery elsewhere for benign lesions of the breast. 

Because some authors believe cystic disease of the breast to be a pre- 
cancerous lesion and recommend simple mastectomy for its treatment, the 
management of this disease poses two important questions for the clinical 
surgeon: What advice is he to give patients who consult him with painful 
nodular breasts, and what source of authority will provide him with an 
intelligent answer for such patients? When a diagnosis of cystic disease is 
established, the author assures the patient that there is no more likelihood 
of carcinoma developing in her breast than in that of any patient of com- 
parable age without cystic disease; and that simple mastectomy is not nec- 
essary except in rare cases. Patients in the earlier period of menstrual 
life with small nodular painful breasts are administered progesterone in 
oil, 20 mg. twice weekly for 2 weeks before menstruation which gives some 
symptomatic relief. 

Since 1933, the author has used aspiration therapy for discrete cysts 
of the breast, provided the patient agrees to return at regular intervals for 
further evaluation. This procedure is more economical for the patient and 
in only 7 of the 167 patients with discrete lumps treated by aspiration was 
there a residual mass following dry aspiration. These patients had surgical 
excision of the tumors which were benign in all 7 cases. 

Patients with discrete cysts are advised that if aspiration produces 
bloody fluid, if the lump does not completely disappear following aspiration, 
if fluid is not obtained, or in the event that the lump returns after a second 
aspiration, the involved area of breast will be excised for histologic exam- 
ination. Regular follow-up examinations of patients in whom aspiration was 



Medical News Letter, Vol. 32, No. 8 II 



performed demonstrated that, in. no instance, was carcinoma overlooked. 
Of 314 patients who had either a discrete cyst or an area of cystic disease 
localized to one segment of the breast, 311 had surgical excision of the 
involved area. Three patients had simple mastectomy due to severe mas- 
todynia and to the fact that the involved breasts were riddled with small 
cysts; in all 3 cases, there was history of breast cancer in several mem - 
bers of the immediate family. 

Sixty-seven patients, treated either with aspiration therapy or sur- 
gical excision of a discrete cyst or segment of breast affected with cystic 
disease, developed a second cyst in the same or opposite breast after a 
period of several months to 16 years. The new cysts were successfully 
treated by aspiration therapy. (Hendrick, J. W. , Results of Treatment of 
Cystic Disease of the Breast - Five to Eighteen-Year Survey; Surgery, 
44 : 457-481, September 1958) 

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Excision of More than Twenty -Five 
Percent of Body Surface 

Although the survival time of extensively burned patients has increased, 
modern advances in therapy have not appreciably decreased the mortality 
rate in this group of patients. If the percentage of area burned for 412 pat- 
ients treated between 1952 and 1956 is plotted against the percentage of 
mortality, it is noted that a 55% total body burn is associated with a 50% 
mortality rate. This experience differs little from the mortality rate 
reported by Bull and Fisher for 967 cases treated between 1948 and 1952 
where a 50% total body burn was associated with a 50% mortality rate. 

The influence of infection upon the mortality rate is clearly defined 
when the causes of 86 deaths occurring between 1950 and 1956 at the U.S. 
Army Surgical Research Unit are analyzed. Of the 86 deaths, 50 resulted 
from invasive infection or septicemia. In addition to the 50 deaths resulting 
from septicemia, 10 proved cases of septicemia survived. 

The organisms isolated from this group of patients and their antibiotic 
sensitivity patterns are shown. Micrococcus pyogenes was recovered in 65% 
of the cases and found to be sensitive to chloramphenicol (Chloromycetin), 
bacitracin, erythromycin, and novobiocin (Cathomycin). Pseudomonas and 
Proteus were recovered in 35% and 20% of the cases, respectively, and 
were found to be sensitive to polymyxin and chloramphenicol. 

Despite all of the 60 patients being treated with this specific antibiotic 
therapy, only 10 survived. Those patients who died had a mean total body 
burn of 60% and a mean area of third-degree burn of 40%, as opposed to a 
mean total body burn of 40%, and a mean area of third-degree burn of 20% 
in those patients who survived. The mean date of onset of septicemia was 



12 Medical News Letter, Vol. 32, No. 8 



the 11th postburn day, and the mean day of death due to septicemia was the 
21st postburn day. 

"When the interval between burning and the initial positive blood cul- 
ture is plotted, for this group of patients, a precipitous rise in the number 
of positive blood cultures is noted on the 5th postburn day. If the areas of 
full -thickness burn harboring these bacteria could be removed prior to this 
period of invasion and the resulting wound closed with skin grafts, the 
hazards of septicemia might be circumvented. 

In September 1955, an evaluation was planned to test this hypothesis. 
Cases were selected on the basis of an unexpected mortality rate of 50%. 
Subjects studied ranged from 5 to 55 years of age. Patients included had a 
burn index (third degree, also one -half second degree) in the range of 35 
to 60, with 25% or more of the body surface involved in full -thickness burn. 
The patients admitted after the fifth postburn day were treated by conventional 
methods and those admitted prior to this time were included in the excisional 
group. All confluent areas of full-thickness burn involving at least 25% of the 
total body surface were excised. This was done in one or two stages between 
the 2nd and the 5th postburn days. Autograft and/or homograft coverage was 
performed immediately, or 48 hours after excision. 

The extent of excision was determined by the patient's ability to dis- 
criminate sharp pinprick. When possible, adjacent questionable areas of 
full -thickness burn were included in the area of excision to insure primary 
wound healing. All areas were excised down to the underlying superficial 
fascia. Two or more surgical teams were required to keep the operative 
time under 2 hours for each procedure. During the immediate postexcisional 
period, a definite clinical improvement was noted in all patients. An interval 
of 48 hours was usually allowed between the excisional procedure and the 
application of grafts. All remaining unburned skin was utilized for autografts 
at the time of the first grafting procedure. Homografts were used to complete 
the initial skin coverage. The period of protection afforded by the homografts 
varied from 2 to 4 weeks. 

Since September 1955, this study has included 22 patients, 14 patients 
being treated by early excision and 8 patients being treated by conventional 
methods. Two of the 8 patients treated by conventional methods survived. 
Initial grafting in these two patients was started on the 32nd and 24th postburn 
days, respectively. Autogenous skin coverage was completed on the 90th 
and 135th postburn days, respectively. The remaining 6 patients developed 
septicemia between the 7th and 26th postburn day. The mortality rate in the 
group treated by conventional methods was 75%. 

The fourteen patients treated by early excision were divided into three 
groups. In the first group of five patients, there were two survivors and 
three deaths. Complete autogenous skin coverage was accomplished in the 
two survivors on the 30th and 37th days, respectively. The three deaths in 
this group resulted from septicemia in one patient who died on the 33rd 



Medical News Letter, Vol. 32, No. 8 13 



postburn day; from a pulmonary infarction in one patient who died on the 
42nd postburn day; and from an accidental death in one patient who died on 
the 33rd postburn day. 

In the second group of five patients, there were three survivors and 
two deaths. Complete autogenous skin coverage was accomplished in the 
three survivors on the 39th, 42nd, and 38th postburn days, respectively. 
The two deaths in this group resulted from septicemia in one patient on the 
10th postburn day and from a Curling's ulcer in one patient on the 37th post- 
burn day. 

In the third group of four patients, there were three survivors and 
one death. Complete autogenous skin coverage was accomplished in these 
three patients on the 31st, 35th, and 54th postburn days, respectively. The 
one death in this group resulted from septicemia on the 34th postburn day. 

The mortality rate in the excisional group of patients was 42% as 
compared with a mortality rate of 75% in the group of patients treated by 
conventional methods. The mean day of complete autogenous skin coverage 
for the excisional group was. the 40th postburn day as compared with the 90th 
and 135th postburn days for the two patients who survived in the group treated 
by conventional methods. 

While the fourteen cases presented are too small a series from which 
to draw definite conclusions, certain pertinent observations can be made. 

Surgical stress of the magnitude described has been well tolerated and 
has resulted in no operative deaths. Removal of areas of full -thickness burn 
involving 25% or more of the total surface has resulted in a temporary im- 
provement in the patient's general clinical condition. 

Homografts have been used effectively as a method of temporary wound 
closure. The shortened period between burning and complete autogenous 
skin coverage has resulted in a marked decrease in postburn morbidity. The 
incidence of septicemia has been influenced by early removal of large areas 
of full -thickness burn. 

Experience with this method of treatment gained to date justifies its 
further critical evaluation. (MacMillan, B. G. , Early Excision of More than 
Twenty-Five Per Cent of Body Surface in the Extensively Burned Patient - 
An Evaluation: Arch. Surg. , 77j 369-374, September 1958) 

$ $ $ j{c ije $ 

Change of Address 

Please forward requests for change of address for the News Letter to: 
Commanding Officer, U. S. Naval Medical School, National Naval Medical 
Center, Bethesda 14, Md. , giving full name, rank, corps, and old and new 
addresses, 

$ £ $ :$ $ $ 



14 Medical News Letter, Vol. 32, No. 8 

Cardiac Glycosides in Medical Practice 

This article summarizes present knowledge concerning the action of 
the digitalis glycosides and discusses the choice of the various glycosides 
in congestive heart-failure. 

The primary action of digitalis is on the heart. Its action on the myo- 
cardium may be conveniently divided into three components: (1) blocking of 
atrioventricular conduction, (2) increasing the contractility of the heart mus- 
cle, and (3) cardiac slowing, direct and through vagal stimulation. 

Digitalis and its preparations are absorbed from the gastrointestinal 
tract. There is no convincing evidence that the alimentary juices affect the 
glycosides deleteriously. Absorption usually is complete in 6 to 8 hours. 
Gold and his associates have shown that the principal glycoside of digitalis, 
digitoxin, is completely absorbed from the gastrointestinal tract. Destruc- 
tion by the liver has also been excluded because the oral and intravenous 
doses of the glycoside are nearly identical. Gitoxin and gitalin are less 
effectively absorbed. 

The fate of the digitalis glycosides in the body is not completely under- 
stood. The glycosides accumulate and then undergo a rather uniform rate 
of degradation for long periods. This has great clinical advantage. Once 
the heart is digitalized by repeated dosage, with cumulative effect, a so- 
called maintenance dose may be given. For the average patient, this is 
100 to 200 mg. of the powdered leaf. This represents the amount destroyed 
and excreted daily. The degradation is believed to occur in the liver. 

There are numerous cases of digitalis poisoning owing to failure to 
recognize the danger signals. In most instances, only doses that produce 
some minor toxic symptoms will achieve the full therapeutic effect of digitalis. 
The most frequent toxic symptoms are nausea and vomiting; when they per- 
sist, the dosage should be reduced. Signs and symptoms of digitalis intoxi- 
cation do not occur in regular sequence. Headache and nervous irritability 
may precede or accompany gastrointestinal distress. Greenish-yellow vision 
and flickering sensations are common. Visual symptoms are a frequent and, 
almost always, a faithful symptom of intoxication in a patient receiving 
digitalis. Abdominal pains, parasthesias, tingling of extremities, and facial 
neuralgia also have been noted. 

Cardiac manifestations that may occur are extra ventricular systoles 
resulting from hyperirritability of the heart. These may pass into ventricu- 
lar fibrillation and lead to death. Intravenous use of the pure glycosides 
must be enjoined with great caution owing to the incidence of toxic mani- 
festations. 

In choosing a satisfactory digitalis preparation, there are three impor- 
tant considerations: (1) the latent period before action, (2) rate of dissipation, 
and (3) rate and completeness of absorption. For routine use, the official 
digitoxin appears to be the drug of choice. The dose for complete digitalization 



Medical News Letter, Vol. 32, No. 8 15 



is about 1.25 mg. Absorption is complete orally and its standardization 
has been effectively accomplished. Complete effect is achieved in between 
6 and 10 hours. For an acutely decompensated patient, this latent period 
is lengthy and a single intravenous injection of 0. 5 mg. of ouabain (stro- 
phanthin) is indicated. The effect appears within 10 to 30 minutes; more 
of the drug may be given, 0. 1 mg. at half-hour intervals up to a total of 
1 mg. The period of dissipation for ouabain is short; that for digitoxin is 
long. Ouabain is not available for oral use. 

The advantage of a short period of dissipation is obvious if toxic 
manifestations occur as the rapid degradation and excretion of the drug 
may soon terminate the toxic effects. With digitoxin, they may persist for 
long periods due to the drug's prolonged period of action before dissipation. 
This is an advantage in the routine use of the drug for maintenance therapy. 
The effect of a single dose of digitoxin may last 8 to 12 days. 

Digoxin obtained from Digitalis lanata is rapidly active and has a short 
dissipation period. It is absorbed by the oral route, but not completely. It 
has been claimed that medication with Digoxin affords greater freedom'from 
toxic manifestations than does medication vvith digitoxin. It is doubtful if 
this claim can be substantiated in the general run of cardiac patients. Work 
by Batterman and DeGraff in 1947 indicates that digitoxin stands at no dis- 
advantage compared with Digoxin. The average digitalizing dose of Digoxin 
is from 1 to 2 mg. and the maintenance dose is 0. 75 mg. 

Amorphous gitalin is gaining prominence as a cardiac glycoside. Like 
Digoxin, it has a short period of dissipation. Batterman, DeGraff, and Rose 
found that gitalin exhibited a margin of safety greater than digitalis leaf, 
digitoxin, or Digoxin. Absorption was dependable in their series of patients. 
On the average, for therapeutic effect, 100 mg. of digitalis leaf was equiva- 
lent to 0. 46 mg. of gitalin. On the other hand, for toxic manifestation, 100 mg. 
of digitalis was equivalent to 0. 65 mg of gitalin. Gruhzit and Farah observed 
that gitalin did not exhibit a greater margin of safety (between the therapeutic 
and toxic doses) than did the other cardiac glycosides. A Table gives approx- 
imate doses of cardiac glycosides for oral and parenteral therapy. (Krantz, 
J. C. Jr., The Cardiac Glycosides in Medical Practice: Postgrad. Med., 
24 : 224-230, September 1958) 

4c 4c s{e $ 4e jfe 

Postoperative Myocardial Infarction 

Myocardial infarction is not an uncommon postoperative complication; 
it is particularly prevalent in the older age group. Recent data suggest 
that myocardial infarction is responsible for 10% of the deaths following 
major operations in patients above the age of 60 years. The incidence may 
be even greater because necropsies indicate that the clinical diagnosis of 



16 Medical News Letter, Vol. 32, No. 8 



myocardial infarction as the cause of sudden death is missed in about 50% 
of the cases. This study presents 3 years' experience at the Graduate 
Hospital of the University of Pennsylvania with postoperative myocardial 
infarction and discusses the predisposing and precipitating factors, clinical 
findings, early diagnosis, and possible methods of prevention and treatment. 

Surgery in the older age group and in patients with preexisting cardio- 
vascular disease — particularly with coronary artery involvement — entails 
an added risk and the danger of coronary thrombosis. The problem of pre- 
vention of these complications is of considerable importance. 

The mortality of subjects with postoperative myocardial infarction 
varies within a wide range — from 30 to 66%. In the present series, the 
mortality was 31. 4%. 

The prognosis in the individual patient depends on many factors: 
preexisting degree of coronary artery damage, the extent of the infarcted 
area, and the presence of complicating visceral diseases. In the older age 
group, the prognosis in rather extensive infarcts is poor. It is hoped that 
early diagnosis and appropriate therapy may be of help in decreasing this 
mortality. 

The problem of postoperative myocardial infarction has assumed in- 
creasing importance because of the frequency of operative procedures in 
patients with coronary disease — particularly in the older age group. The 
authors' experience is recorded relative to the development of postoperative 
myocardial infarction over a period of 3 years. During this period, 35 patients 
with this complication were observed in a series of 21, 000 operations. Although 
this complication was observed more frequently during major operative pro- 
cedures, it is of interest that it was also observed with minor operations. 
The clinical picture, diagnosis and the differential diagnosis are discussed. 
The presence of preexisting heart damage particularly involving the coro- 
nary arteries in the older age group is an important predisposing factor. 

The occurrence of a hypotensive state during operation is an impor- 
tant precipitating factor. The possible prevention and early recognition and 
treatment of the hypotensive state may be of help in preventing or decreas- 
ing the size of the infarcted area, (Feruglio, G. , Bellet, S. , Stone, H. , 
Postoperative Myocardial Infarction: Arch. Int. Med., 102:345-352, 
September 1958) 

Cardiac Surgery Associated with Pregnancy 

A report of the experience of the United States Naval Hospital, San 
Diego, Calif. , in the field of cardiac surgery associated with and during 
pregnancy affords the basis for this article and may be considered as a 
preliminary report. 



Medical News Letter, Vol. 32, No. 8 17 



The most common lesion of the heart associated with pregnancy is 
rheumatic mitral stenosis. The aim of mitral commissurotomy is to reduce 
or remove the obstruction to the blood flow imposed by the diseased valve 
without creating incompetence or regurgitation. For the patient to be a 
candidate for surgery in pregnancy, she must have a lesion so incapacitating 
that its correction is imperative enough to warrant the risk. The valvular 
lesion must be of a type amenable to operation, and the stenosis must be 
the cause of enough of the patient's disability that its correction will result 
in a definite upgrading of her cardiac classification. 

The diagnosis of rheumatic mitral stenosis in the pregnant patient 
does not significantly differ from that in the nonpregnant state. A history 
of one or more of the components of the rheumatic diathesis is present in 
about two-thirds of patients. In many instances, the patient has known mi- 
tral valvular disease prior to pregnancy and the obstetrician will be asked 
to follow the patient in close conjunction with the referring internist. 

During the 4-year period from 1953 to 1956, inclusive, there have been 
39 cardiac operations performed on female patients over the age of 15 years 
at the U. S. Naval Hospital, San Diego, Calif. Twelve of these patients were 
nulligravidas and are not included further in the study. There were a total 
of 62 pregnancies in the remaining 27 patients studied. Prior to operation, 
there had been a total of 38 full-time deliveries; one of the infants was a 
Mongoloid and did not survive. There were no therapeutic abortions before 
operation in any of the 27 cases. There had been 13 abortions, 9 of which 
were in 1 patient, but none were therapeutically induced. One patient had 
one delivery followed by a commissurotomy. She subsequently became 
pregnant and went into severe cardiac failure prior to the third month of 
gestation, so therapeutic abortion and tubal ligation were performed. Seventy 
percent of the 27 patients in this report showed marked improvement of the 
cardiac symptoms after operation and only 2 showed no improvement. Four 
suffered from embolic phenomena following operation. There were 3 deaths 
resulting in an operative mortality of 11%. 

Eight patients were pregnant at the time of operation. Two had coarc- 
tations of the aorta; both of these were delivered of viable term infants with- 
out difficulty following surgical repair of the lesion and one has since under- 
gone an uncomplicated pregnancy. Six patients had mitral commissurotomies 
for stenosis. One died during operation. One was delivered of a premature 
infant at 31 weeks' gestation (9 weeks following operation). This infant died 
and was found at autopsy to have had numerous congenital anomalies. One 
Mongoloid infant was delivered at term. Three patients were delivered of 
normal term infants subsequent to their operations. 

From analysis of the data, the following conclusions seem justified: 
Certain selected cases of mitral stenosis and most coarctations of the aorta 
can successfully be surgically repaired with a minimum of morbidity and 
an acceptable mortality rate in the gravid woman. The operation is best 



18 Medical News Letter, Vol. 32, No. 8 



performed on the pregnant woman prior to the twenty-eighth week of gesta- 
tion in order to escape the peak load of pregnancy. 

Mitral commissurotomy is indicated in all Class III and Class IV 
pregnant cardiac patients who are being considered for interruption of preg- 
nancy on the basis of failing cardiac reserve, provided the valvular lesion 
is considered amenable to surgical correction. Pregnancy is not considered 
a contraindication to operation on the heart or great vessels if performed 
prior to the twenty-eighth week of gestation. 

Cardiac surgery does not appear to affect the fetus adversely or to 
increase the incidence of prematurity if performed prior to the twenty-eighth 
week of gestation under the protective influence of progestational hormone 
therapy. 

Therapeutic abortion as a means of terminating a pregnancy on the 
basis of mitral stenosis is rapidly becoming an obsolete method of man- 
agement as a result of the successful utilization of mitral commissurotomy 
in indicated cases and good conservative management in the remainder. 

In view of the definite improvement that can be anticipated from a 
mitral valvulotomy, tubal ligation is no longer indicated in any case requir- 
ing therapeutic abortion on the basis of cardiac failure due to mitral heart 
disease. (LTW.E. Winter MC USN, D. B. Carmicheal, M. D. , and I. D. 
Baronofsky, M. D. , CAPT W. S. Baker Jr., MC USN, Cardiac Surgery 
Associated with Pregnancy: Am. J. Obst. & Gynec. , 76:573-585, September 
1958) 

£|c s£c *f. ¥£. 5jC Sjc 

Deck Foot 

Recent experience at the Naval Hospital, Guantanamo Bay, Cuba, 
has indicated that an unusual entity is becoming more frequent. This con- 
dition has been called "Deck Foot" because it occurs primarily in uncon- 
ditioned men after being at sea in tropical climates on steel decks. The 
clinical picture is one of edema, erythema, local heat, petechial hemorrhages, 
and moderate to severe tenderness without constitutional symptoms. X-Rays 
are negative for "stress" fractures, and the edema extends from the toes 
to the mid-tibia at times. The onset occurs from 3 to 14 days after arrival, 
and recovery after 3 days to 2 weeks of bed rest and elevation of the extre- 
mities. It is rare to have a recurrence even though men are returned to 
full duty at their previous jobs. 

The cause of this entity is unknown, but there seems to be no vascular 
component other than the petechia. It might better be called "stress" edema 
or cellulitis, as a similar condition is described in poorly conditioned indi- 
viduals who suddenly have to stand or walk for long periods. (ProfDiv, BuMed) 

3£C 5JC >[C i d < 5JC ^fi 



Medical News Letter, Vol. 32, No. 8 19 



Voluntary Retirement 

Retirement after 20 or more years of service has been authorized 
since 1955, and a number of Medical Department officers have been granted 
this early retirement. It is felt that the availability of early retirement is 
a distinct addition to the attractiveness of a Navy career. 

vVhile general information on voluntary retirement appears to be 
widely distributed, letters and comments received indicate that some of 
the details are less widely known. The specific criteria prescribed by the 
Secretary of the Navy as meriting favorable consideration for early retire- 
ment are stated in SecNav Instruction 1811. 3A of 10 September 1955, and 
anyone thinking of making such a request should be fully acquainted with 
this instruction as well as BuPers Instruction 1811. 1A of 19 July 1957. 

Among the six criteria listed is that of five years' service in grade 
for captains as well as 20 years' total service. Other of the listed criteria 
may be applicable to individual cases. Requests are considered on a basis 
of the over-all needs of the Service and the merits of the individual case. 

Requests should be submitted at least three months and not more than 
six months ahead of the desired date, and the preretirement physical must 
be reported to the Chief of Naval Personnel from one to three months in 
advance. BuPers requires that officers starting a new tour of duty complete 
at least one year at the new station before voluntary retirement is effected. 

Obviously, an unexpected request for retirement creates problems 
in connection with a relief, and in some instances insufficient time has been 
allowed in which to arrange for a relief. Consequently, it is most desirable 
that BuMed be informed of prospective retirement plans as far as possible 
in advance of the prescribed three months lead time to insure that the de- 
sired retirement date can be met. 

The Bureau is in no sense urging officers to consider early retire- 
ment. This note is simply to urge those who may be thinking of early 
retirement to become familiar with the requirements and proper procedure 
as detailed in SecNav and BuPers Instructions. (PersDiv, BuMed) 

&$$:£$$ 

Opportunities in Submarine Medicine 

Associated with the rapidly expanding underwater activities of the 
Navy, there is an increasing number of opportunities in submarine medicine. 
There are some unfilled vacancies in the course for Submarine Medical 
officers convening in January 1959. Following a 6 -months indoctrination 
which includes practical orientation in submarine and diving operations, under- 
water physiology, occupational medicine problems of submarines, and short 
training cruises, a wide variety of duty assignments is available. Some of 



20 Medical News Letter, Vol. 32, No. 8 



these have associated extra pay. Among these are duty with organ- 
izations engaged in diving activities, teaching, research, and service with 
the operational submarine force. Greatest emphasis at this time is placed 
on training for duty with the nuclear powered submarines. Currently, this 
is achieved by an academic year spent in the study of radiation biology fol- 
lowed by a period of practical experience at an AEC reactor site. Active 
plans are under way to provide an alternate condensed period of training 
in this field which will equip the medical officer adequately for this duty in 
a period of 6 to 8 months. Much of the Submarine Medicine program of 
training has been approved for specialty training in one or another field. 
Anyone interested in this new and unusual facet of medical science 
is encouraged to write to: Director, Submarine Medicine Division (Code 75), 
Bureau of Medicine and Surgery, Washington 25, D. C. for more details. 

(SubmarMedDiv, BuMed) 

# $ $ $ $ 41 

Submarine Medicine Technic Training; - 



Applicants Desired 

As a result of the expanding operational requirements of the Nuclear 
Powered Submarine Training program, applications for initial training in 
Submarine Medicine Technic are desired. Applications are particularly 
needed from highly qualified career minded personnel of the HM rating in 
pay grades E-5, E-6, and E-7. 

In general, eligibility requirements are summarized as follows: 

a. Obligated Service - 24 months commencing on convening date of 

the class.. 

b. Be a volunteer for sea duty in submarines. 

c. GCT & ARI or ARI & MECH of 100. Requests for 
waivers will be considered on individual merits. 

d. Be physically qualified for submarine duty. 

e. Age limits are not established. 

All commands are requested to give wide publicity to the continuing 
need for well qualified applicants for training in this specialty. 

Applicants should familiarize themselves with the contents of BuPers 
Instruction 1540. 2C for additional information. (ProfDiv, BuMed) 

A A A A A !& 

Use of funds for printing this publication has been approved by the 
Director of the Bureau of the Budget 19 June 1958. 

3k Jflt sBi 5p JK S|C 



Medical News Letter, Vol. 



32, 



No. 8 



21 



American Board of Obstetrics and Gynecology 

The Part I Examinations of the American Board of Obstetrics and 
Gynecology are to be held in various parts of the United States and Canada 
on Friday, January 16, 1959 at 2:00 p.m. 

Candidates notified of their eligibility to participate in Part I must 
submit their case abstracts within thirty days of notification of eligibility. 
No candidate may take the Written Examination unless the case abstracts 
have been received in the office of the Secretary. 

Current Bulletins outlining present requirements may be obtained by 
writing to the Secretary's office. 



Office of the Secretary: 



Robert L. Faulkner, M. D, 
2105 Adelbert Road 
Cleveland 6, Ohio 



SJI jjt =}: ff 5|C 3{C 



MSC Guest Lecture Series 



The Medical Service Corps Guest Lecture Series for 1958-1959 will 
be held at the U. S. Naval School of Hospital Administration, National Naval 
Medical Center, Bethesda, Md. The following lecturers are scheduled: 



Date 



Speaker 



Position 



Oct 17, 1958 Kenneth B. Babcock, M. D. 



Director, Joint Commission 
on Accreditation of Hospitals, 
Chicago, 111. 



Nov 21, 1958 John P. Hagen, Ph.D. 



Director, Project Vanguard, 
U. S. Naval Research Labor- 
atory, Washington, D. C. 



Jan 16, 1959 



Feb 20, 1959 



Edwin L, Crosby, M. D. 
George W. Latimer 



Director, American Hospital 
Association, Chicago, 111. 

Associate Judge, U. S. 
Court of Military Appeals, 
Washington, D. C. 



Mar 20, 1959 James A. Hamilton 



Professor and Director, 
Course in Hospital Admin- 
istration, Univ. of Minn. 



22 Medical News Letter, Vol. 32, No. 8 



Dental Officers Memorial 

Arrangements for a thirty -one chair section to memorialize deceased. 
Dental officers have been completed with officials in charge of the Navy- 
Marine Corps Memorial Stadium which is well on the way toward comple*- 
tion at the U. S. Naval Academy, Annapolis, Md. Dental officers, both 
Reserve and Regular, together with business houses associated with dentis- 
try donated a total of $3, 117 to finance the Memorial. 

Each of the thirty-one chairs will have a small plaque telling the 
officer's name, rank, and corps plus apropos information, such as decor- 
ations awarded and the battlefield or ship on which he fell. The group 
includes officers killed in battle in World War I and II together with other 
types of war casualties in World War II and in Korea. One chair will mem- 
orialize Vice Admiral Alexander G. Lyle, first Dental Corps Admiral and 
winner of the Medal of Honor in World War I. Dental Reserve Company 
5-5 of Louisville, Ky. , and 9-3 of Chicago, 111. , contributed funds to mem- 
oralize three deceased Reserve Dental officers who were not war casualties. 
Another chair memorializing Captain Thomas J. Ownby DC USN was arranged 
for by his shipmates at the Naval Dental Clinic, Brooklyn, N. Y, 

Those who will be honored in the Dental Memorial Section are: 

Killed in Action in World War I 

LT Weeden E. Osborne DC USN 

Killed in Action in World War II 

CDR Wadsworth C. Trojakowski DC USN 

LCDR Hugh R. Alexander DC USN 

LCDR Earl O. Henry DC USNR 

LCDR Farrell W. Keith DC USNR 

LCDR Laurie e A. Tatum DC USNR 

LT Edward A. Baumbach DC USNR 

LT Thomas P. Capps DC USN 

LT James C. Gate DC USNR 

LT Thomas E. Crowley DC USN 

LT Stanley E. Ekstrom DC USNR 

LT Gilbert F. Gorsuch DC USN 

LT Charles W. Holly, Jr. DC USN 

LT Stephen M. Lehman DC USNR 

LT Edward J. O'Reilly DC USN 

LT Robert W. Seeger DC USNR 

LT Miller C. Wonn DC USNR 

LTJG Thomas R. Mclntyre DC USNR 



Medical News Letter, Vol. 32, No. 8 23 



Killed or Died as Prisoners of War in World War II 

LCDR James A. Connell DC USN 
LT Henry C. Knight DC USN 
LT Alfred F. White DC USN 
LTJG Robert C. Herthneck DC USN 

Deceased While Serving Outside United States (Not in Action) 

CDR James L. Lea DC USNR 

LT Fred M. Stone DC USNR 

LT John T. Wieland DC USNR 

LTJG Thomas G. Cherikos DC USNR 

Deceased Officers Being Honored by Friends 

VADM Alexander G. Lyle DC USN 
CAPT Thomas J. Ownby DC USN 
CDR J. R Bailey DC USNR 
CDR J.I. Essig DC USNR 
LT John W. Knox DC USN 

All hands are heartily thanked and congratulated for their contributions 
which made the memorial chair section possible. (DentDiv, BuMed) 

$ 3$E $S $ 3(c $ 

IN MEMORIAM 



RADM Charles Weite O. Bunker MC USN (Ret) 17 September 1958 

RADM Cornelius H. Mack DC USN (Ret) 22 August 1958 

CAPT George S. DeShazo DC USN (Ret) 27 August 1958 

CDR Frederick G. Abeken MC USN (Ret) 23 September 1958 

LCDR Ralph P. Morse DC USN (Ret) 12 August 1958 

LT Arthur W. Picard MSC USN (Ret) 24 August 1958 

CWO Walter E. Quenstedt HC USN (Ret) 10 September 1958 

CWO Roy E. Wahl MSC USN (Ret) 12 September 1958 

i$E 3|t 3|E 3f£ 3|C 3g( 

From the Note Book 

1. CAPT W. C. Calkins MSC USN, first Chief of the Navy Medical Service 
Corps, was placed on the list of retired officers on 1 October 1958 after 
four years in office and more than thirty-nine years of active naval service. 

(TIO, BuMed) 



24 Medical News Letter, Vol. 32, No. 8 



2. CAPT L. J. Elsasser MSC USN has been appointed Chief of the Navy 
Medical Service Corps. He succeeds CAPT W. C. Calkins. (TIO.BuMed) 

3. CAPT R. R. Eambo MC USN, who for several years has been the Medical 
Director of the Navy Mutual Aid Association, was recently appointed a Vice 
President of the Association. CAPT Rambo's new duties will be in addition 
to those of Medical Director. (TIO, BuMed) 

4. Early detection of staphylococcal infections in hospitals, rigid measures 
to prevent their spread, and increased research to find better methods of 
preventing and treating them have been recommended by the National Con- 
ference on Staphylococcal Disease. The Conference, cosponsored by the 
Public Health Service and the National Research Council, was attended by 
delegates from 59 professional organizations and numerous authorities on 
various aspects of the infection problem. (PHS, HEW) 

5. A rapid, accurate colorimetric method for detecting and measuring 
minute quantities of acetylene in air (as low as 10 parts per billion) has been 
developed by the National Bureau of Standards in cooperation with the U. S. 
Public Health Service. (NBS) 

6. This article discusses the practice of toxicology and defines clinical 
toxicology as that branch of medicine concerned with prevention, diagnosis, 
and treatment of conditions produced by poisons, (Postgrad. Med. , Sept. 
1958; W. J. R. Camp) 

7. This report is a study of 52 cases of malignant pleural effusion by the 
Vim -Silverman needle biopsy technique. Of these cases, 50 were also 
studied for malignant cells by the Papanicolaou technique. (Cancer, Sept. - 
Oct. 1958; M. L. Samuels, M. D. , J.W. Old, M. D. , CD. Howe, M. D. ) 

8. A relatively simple technique for obtaining urine cultures from female 
patients based on the use of sterile voided urine collections and a quantita- 
tive culture technique is described and evaluated by comparison with cath- 
erized urine collections. (J. Lab. & Clin. Med., September 1958; A. D. 
Merritt, M. D. , J. P. Sanford, M. D. ) 

9. Twenty-seven full thickness burns of the dorsum of the hand have been 
treated by early excision and grafting. Of the 21 hands in the surviving 
patients, 12 regained a completely full range of motion. In the remainder, 
the return of function was adequate for all but finely coordinated activity. 
Split thickness grafting resulted in elastic skin coverage with no need for 
revision of covering of the dorsum of the hand. (Am. J. Surg. , October 1958, 

J. A. Moncrief, M. D. ) 



Medical News Letter, Vol. 32, No. 8 25 



10. The effect of albumin and globulin fractions (isolated by the electro- 
phoretic technique from the serum of apparently healthy individuals and 
from patients with infectious hepatitis, post-hepatic jaundice, hepatic cir- 
rhosis, rheumatoid arthritis, lupus erythematosus and subacute bacterial 
endocarditis) upon the cephalin-chole sterol, colloidal red, colloidal gold, 
colloidal blue, thymol and distilled water tests, have been studied for the 
purpose of elucidating the mechanisms of these tests. (Gastroenterology, 
September 1958; R. Armas-Cruz, M. D. et al. ) 

11. A review of 30 cases of periodic neutropenia collected from the litera- 
ture is presented to emphasize that this disease is no longer extremely rare. 
The indication for splenectomy is outlined and the cases having had splenec- 
tomy are reviewed to substantiate that this indication is correct. (Arch. Int. 
Med., September 1958; G.W. Duane, M. D. ) 

12. The place of local anesthesia in surgery is discussed from the stand- 
point of the operator and that of the patient. Methods of application, anes- 
thetic agents, dosage, and potential hazards are described. (Arch. Surg., 
September 1958, D. M. Glover, M. D. ) 

13. Two cases are reported of a fatal syndrome of refractory watery diar- 
rhea, hypokalemia, and vacuolar nephropathy in association with non-insulin- 
secreting islet cell adenomas of the pancreas. (Am. J. Med. , September 
1958; J.V. Verner, M. D. , A. B. Morrison, M. D. ) 

14. The management of perforated peptic ulcer is discussed. (Surgery, 
September 1958; C. J. Berne, M. D. W.P. Mikkelsen, M. D. ) 

15. An editorial by Dr. Helen B. Taussig in September 1958 Circulation 
discusses the selection of patients for surgical repair in congenital defects 
of the heart. 

I 

a^ $ sjc j$ 9$$ fy 

Recent Research Reports 
Naval Dental Research Facility, NTC, Bainbridge, Md . 

1. Survey of Dental Health. III. Tooth Brushing Habits. NM 75 01 26. 04, 
2 June 1958. 

2. Characteristics of Saliva of Dental Caries Free and Dental Caries 
Rampant in Young Male Adults. NM 75 01 26. 02. 02 and NM 75 01 26. 03. 01, 
15 July 1958. 



26 



Medical News Letter, Vol, 32, No. 8 



3. Microscopic Study of Saliva Sediment. II. The Cellular Elements of 
Saliva and Their Relation to Dental Caries Experience and Gingivitis. 
NM 75 01 26. 06, 15 August 1958. 

Naval Medical Research Institute, NNMC, Bethesda, Md . 

1. Typical Behavior of Some Simple Models of Enzyme Action. NM 01 01 00 
.02.03, 9 January 1958. 

2. Hemolytic Effect of Ionizing Radiations and Its Relationship to the Hemor- 
rhagic Phase of Radiation Injury. NM 62 02 00.01.03, 21 March 1958. 

3. IFR Flight without Attitude Instruments. NM 15 01 00. 01. 01, 25 April '58. 

4. Further Studies on Host-Cell Preferences by Exoerythrocytic Stages of 
Avian Malaria. NM 52 01 00.02.02, 2 May 1958. 

5. Some Measurements of the Brightness of a Sea Water Surface under Clear 
Weather Conditions. NM 18 01 00.02.02, 15 May 1958. 

6. Nerve Blockade Produced by Holothurin, a Glycosidic Mixture Derived 
from the Sea-Cucumber. NM 02 02 00.01, 28 May 1958. 

7. Cell-Bound Antibodies in Transplantation Immunity. NM 71 01 00,03.01, 

10 June 1958. 

8. Convulsant Activities of Aminocyclanol Derivatives as Influenced by 
Stereochemical Configurations. NM 02 02 00.01.07, 10 June 1958. 

9. Polynucleotides VI. The Influence of Various Factors upon the Structural 
Transition of Polyriboadenylic Acid at Acid pH's. NM 02 01 00. 01. 05, 

26 June 1958. 

10. Summaries of Research. 1 January - 30 June 1958, 30 June 1958. 

11. Quantitative Participation of Fatty Acid and Glucose Substrates in the 
Oxidative Metabolism of Excised Rat Diaphragm. NM 72 02 00. 02. 01, 

11 July 1958. 

12. Demonstration of the Marrow-Vascular Space (Macrocanalicular System) 
of Bone. NM 71 01 00. 06. 02, 1 1 July 1958. 

Naval Medical Research Unit No. 3, Cairo, Egypt 

1. Hunterellus Theileri Fiedler (Encyrtidaf, Chalcidoidea) Parasitizing an 
African Hyalomma Tick on a Migrant Bird in Egypt. NM 52 08 03. 3. 05, 
February 1958. 

2. Cardiopulmonary Studies in Schistosomiasis. Pulmonary Function Tests, 
Hemodynamic and Pharmacodynamic Studies in Bilharzial Cor Pulmonale. 
NM 72 01 03.4 .04, March 1958. 

3. Carcinoma of the Urinary Bladder Associated with Urinary Schistosomiasis 
Malignant Bladder Tumors in Egypt - A Pathological Study of 73 Cases. NM 
52 02 03. 6, May 1958. 

4. Review of the Snake Genus Spalerosophis. NM 52 08 03.7.04, June 1958. 



Medical News Letter, Vol. 32, No. 8 27 

Naval Medical Research Unit No. 4, Great Lakes, 111 . 

1. Isolation of Coxsackie Group B Viruses from Cases of Respiratory 
Illness, Great Lakes, 1957. NM 52 05 04.4.2, 23 July 1958. 

Naval Air Development Center, Johnsville, Pa. 

1. Study of Human Performance Limitations in Aircraft Catapulting with 
a Linear Track; letter report on proposed experimental program. NM 11 
02 12.2, 13 August 1958. 

2. Aviation Textiles and Textile Treatments, Thermal Protection Capacity, 
(Letter report concerning experimental comparison of fire-retardant flight 
suit sample and THPC-APO treated cotton-fortisan fabric and fabrics of 
known optical and thermal properties.) TED ADC AE-5109, 18 August 1958. 

Naval School of Aviation Medicine, NAS, Pensacola, Fla. 

1. Study of Preferences for Type of Naval Air Advanced Training. Report 
No. 1, Subtask No. 8, NM 16 01 11, 6 January 1958. 

2. Investigation of the Magnitudes of Galvanic Skin Resistance Responses 
that Occur with Different Intensity Levels of Shock, Conditioned Tone, and 
Extinction Tone. Report No. 75, Subtask 1, NM 18 02 99, 15 February 1958. 

3. Studies on the G-Tolerance of Invertebrates and Small Vertebrates while 
Immersed. Report No. 2, Subtask No. 1, NM 19 01 11, 1 March 1958. 

4. Effect of the Valsalva Maneuver on Circulation Time. Report No. 13, 
Subtask No. 5, NM 18 03 11, 1 April 1958. 

5. Evaluation of Certain Visual and Related Tests II. Phoria. Report No. 2, 
Subtask No. 6, NM 14 01 11, 17 April 1958. 

6. Accident Data, Instructor Comments, and Student Questionnaire Responses 
as Indicators of Transition Training Problem Areas. Report No. 1, Subtask 
No. 7, NM 14 01 11, 25 April 1958. 

7. Relationship between Cardiovascular Response and Positive G Tolerance. 
Report No. 11, Subtask No. 1, NM 11 01 11, 8 May 1958. 

8. New and Objective Method for Measuring Ocular Torsion. Report No. 46, 
Subtask No. 1, NM 17 01 11, 15 May 1958. 

9. Effects of Rate and Direction of Conditioned Stimulus Change on Avoidance 
Performance. Report No. 4, Subtask No. 12, NM 14 02 11, 15 May 1958. 

10. Ionization Dosage from X- and Beta Rays in Flight through Auroral Dis- 
plays. Report No. 15, Subtask No. 1, NM 12 01 11, 2 June 1958. 

Office of Naval Research, Washington, D. C . 

1. Survey of the Dental Health of the Naval Recruit. Report 58-5, January '58. 
(prepared by Psychological Research Associates, Inc. , Arlington, Va. ) 



28 Medical News Letter, Vol. 32, No. 8 




DENTAL KUWil SECTION 



Experiences and Problems with 
Subperiosteal Implants 

The problems of mandibular and maxillary subperiosteal implants, 
as experienced by Hugo L. Obwegeser of Zurich, Switzerland, were reported 
at the Sixty -Fourth Annual Meeting of the American Dental Society of Europe 
which was held recently in Knokke, Belgium, Thirty-five implants of elec- 
trically polished vitallium were inserted in 32 patients. No wire or screws 
were necessary to hold the implant in place; however, the report stated that 
subperiosteal wire may be used for a short period to insure stability and 
then removed. Three weeks after insertion, the implants were usually 
firmly imbedded and construction of dentures was started. Antibiotics were 
not routinely administered following the surgical procedure. It was found 
that delay in insertion more than 2 weeks after the impressions were made 
increased the possibility of bone absorption and improper fitting of the im- 
plant. 

Some of the complications experienced were: suture infection, hema- 
toma, calculus on the abutments, bone absorption under the implant (the 
tissue following the bone leaving the implant partially exposed), fistulas 
forming around the abutments, and breakage of abutments. The bone absorbed 
so much in some cases that the implant settled enough to put pressure on the 
mental nerves resulting in parasthesia or anesthesia. 

At the time of the report, some of the implants had been in place up to 
3 years. Within the first year after insertion, 30% of the patients had com- 
plications. In instances where the implants had been in place from 1 to 3 
years, 19 patients had tissue inflammation. In another 13 patients, there was 
no inflammation, but 2 had parasthesia, 1 had anesthesia, 1 complained of 
pain during weather changes, and only 9 were free from complications. 

Because two-thirds of the patients experienced complications, the 
author was of the opinion that subperiosteal implants are "an unbiological 
procedure, " and that one could not promise long term satisfactory results. 
He concluded that more research will be required to determine the factors 
responsible for the complications. 

sj; ^c 4; ;;<: i]< >;< 



Medical News Letter, Vol. 32, No. 8 29 



New Dental Corps Exhibit at ADA Meeting in Dallas 

A new U. S. Navy Dental Corps exhibit, Dentistry in the Modern Age, 
will be shown for the first time at the Annual Session of the American Dental 
As sociation in Dallas, Texas, November 10 - 13, 1958. 

The exhibit is 24 feet in length with a back drop depicting the universe 
as representative of the modern space age. The informative material of 
the exhibit includes the use of television as a training aid; the use of radio- 
isotopes in dental research; and U. S. Navy Dental Corps support in the 
Antarctica. This material is presented by means of three movable consoles, 
each of which may be placed in the foreground at the exhibit for demonstra- 
tion. The consoles are designed for independent use in the training program 
at the U. S. Naval Dental School when the exhibit is not scheduled for showing 
at professional meetings. 

Captain V. J. Niiranen DC USN and Captain J. P. Arthur DC USN will 
monitor the exhibit at the Dallas meeting. 

■JC ife SJC 3fe jfc Sfc 




RESERVE SECTION 



Correspondence Course Training 

COMBAT AND FIELD MEDICINE PRACTICE - NavPers 1Q706-A. 1957 
edition, recommended for all Medical Department personnel. 

Medical practice in combat, whether afloat or ashore, raises many com- 
plex problems which tax to the utmost the abilities of departmental per- 
sonnel. The whole effort of the Medical Department achieves its ultimate 
purpose in medical practice during combat. The purpose of this course is 
to enable personnel to perform their combat functions with maximum effec- 
tiveness, to accomplish assigned mission, and to "survive. " This course 
provides a set of principles and flexible formulae which can be applied to 
varying combat conditions. The discussions presented relate to the man- 
agement of battle casualties, care of neuropsychiatric casualties in com- 
bat areas, traumatic shock, medical aspects of tropical warfare, and the 
medical aspects of warfare in extremely cold climates. Prevention and 
control of disease are predicated on the latest opinions and research and 
on the combined experiences of the Armed Forces. 



30 Medical News Letter, Vol. 32, No. 8 



The course consists of four (4) objective type assignments and is eval- 
uated at sixteen (16) Naval Reserve promotion and/or nondisability retire- 
ment points. Naval Reserve personnel who previously completed the 
correspondence course, Combat and Field Medicine Practice, NavPers 
10706, will receive additional credit for the completion of course Nav- 
Pers 10 70 6 -A. 

SUBMARINE MEDICINE PRACTICE - NavPers 10707-A. (Revised 1958) 
(Available on or about 1 November 1958) Recommended for all Medical 
Department personnel. 

This course presents the highlights of latest developments and the 
accumulated knowledge and experience resulting from years of research 
and investigations. It is designed as a comprehensive guide which can be 
utilized for training Medical Department personnel in the many intricate 
problems connected with submarine medicine practice. Recent atomic 
ventures and developments in underwater military operations demand a 
greater surveillance of the medical problems involved. 

Discussions concentrate on personnel selection and assessment pro- 
cedures, improvement of submarine habitability factors, solution of 
human engineering problems aboard submarines, submarine escape and 
rescue operations, and the medical aspects of all other under sea opera- 
tional problems directed toward the improvement of the military effec- 
tiveness of the Submarine and Amphibious Forces. For the medical 
officer interested in the solution of these many unsolved problems, 
Submarine (underwater) Medicine practice offers a most challenging 
field. Increased cruising range and prolonged submergence of modern 
submarines, penetration of greater depths by the deep sea diver, and 
the expanding practice of underwater swimming demand continued effort 
in research. 

The course consists of six (6) objective type assignments and is e'val- 
utated at eighteen (18) Naval Reserve promotion and/or nondisability 
retirement points. Naval Reserve personnel who previously completed 
course NavPers 10707, will receive additional credit for the completion 
of course NavPers 10707-A. 

TROPICAL, MEDICINE IN THE FIELD - NavPers 10995. (Revised 1958) 
(Available on or about 1 November 1958). Recommended for all Medical 
Corps officers. 

During World War II, tropical diseases caused more casualties in 
many areas than did enemy action. Such diseases have long been a ser- 
ious deterrent to successful military operations in the tropics. The 
added experience of recent wars has naturally heightened military interest 
in tropical medicine, especially in the application of the many recent ad- 
vances in medicine to the treatment of tropical diseases. 



Medical News Letter, Vol. 32, No, 8 31 



The purpose of this course is to provide a concise guide in tropical 
medicine not only for the physician practicing in the tropics, but also 
for the physician in temperate zones who may be encountering tropical 
diseases of servicemen and others returning to the United States after 
a tour of duty in the tropics. The course is based upon a Manual of 
Tropical Medicine by Mackie, Hunter, and Worth; it covers the essen- 
tial practical aspects of epidemiology, diagnosis, treatment, and pro- 
phylaxis of the more important tropical diseases. 

Laboratory analysis plays an especially helpful and dramatic role in 
the diagnosis of diseases in indigenous personnel in tropical areas where 
the language barrier may make a provisional diagnosis difficult. Another 
factor to be considered is that natives of tropical areas may react to 
local diseases with symptoms very unlike those exhibited by non-natives. 
The text stresses the importance of military medicine and special effort 
has been directed to the condensation of information essential for the 
Armed Forces, the clinician, field worker, and the student of tropical 
medicine. 

The course consists of twelve (12) objective type assignments and is 
evaluated at thirty-six (36) Naval Reserve promotion and/or nondisability 
retirement points. Naval Reserve personnel who previously completed 
the correspondence course, Tropical Medicine in the Field, NavPers 
(none), edition 1950, will receive additional credit for the completion of 
course NavPers 10995. 

Application Instructions 

1. The form, Application for Enrollment in Officer Correspondence 
Course, NavPers 992 (Rev 1/57) or later revision, should be appro- 
priately filled out and forwarded to the Commanding Officer, U.S. Naval 
Medical School, National Naval Medical Center, Bethesda 14, Md. Make 
the appropriate change in the "To" line in Box J of the application form. 
These forms can be obtained from your Commanding Officer or from 
the respective District Headquarters. 

2. Completed applications will be forwarded as follows: 

a. If on active duty: via your Commanding Officer 

b. If on inactive duty and not in a training program under the 
cognizance of the Chief of Naval Air Reserve Training (CNART): 
via your Naval District Commandant. 

c. If on inactive duty and in a training program under the cogni- 
zance of CNART: via the Commanding Officer of NAS or NARTU having 
responsibility for the training program. 

d. If on inactive duty and residing in a foreign country: via (1) 
the local Naval Attache or Force Commander, if any, and (2) the com- 
mand maintaining your service record (usually your home District 
Commandant). 



32 Medical News Letter, Vol. 32, No. 8 

3. Caution! Do not send applications for enrollment in Medical 
Department correspondence courses to the U.S. Naval Correspondence 
Course Center, Naval Supply Depot, Scotia 2, New York. Such pro- 
cedure delays the processing of the application for several weeks. 
Send to that address only applications for enrollment in courses admin- 
istered by that center. 

Multiple Enrollment. Medical personnel may be enrolled in more than one 
Medical Department correspondence course at one time. 

AVIATION MEDICINE DIVISION 




Naval Aviator - Flight Surgeon 

For a number of years, the Chief of Naval Operations has permitted 
the Chief of the Bureau of Medicine and Surgery to nominate a limited num- 
ber of qualified flight surgeons for training as naval aviators. Those flight 
surgeons who successfully complete the training syllabus are designated 
naval aviators and are ordered to duty as such in the actual control of air- 
craft. This is in addition to duties for which they are assigned as medical 
officers. 

In the near future, there will exist vacancies for several naval aviator - 
flight surgeons and it is desired that deserving, well motivated, 35 years of 
age or younger, and physically qualified Regular U. S. Navy flight surgeons 
fill these vacancies. Successful candidates shall be assigned to test pilot 
billets connected with the human engineering phases of the Navy's devel- 
opmental programs, as well as other related operational and administrative 
assignments. 

Those active duty flight surgeons, U.S. Navy or U.S. Navy Reserve, 
who are particularly desirous of becoming naval aviators are invited to 
apply for flight training by letter request to the Chief, Bureau of Medicine 
and Surgery, Aviation Medicine Operations Division, Navy Department, 
"Washington 25, D. C. Flight surgeons who complete the training and are 
designated as naval aviators shall incur a service obligation of 3-1/2 years 
following date of designation. Applicants should include this service agree- 
ment in their applications. 



Medical News Letter, Vol. 32, No. 8 33 

The Pros and Cons of Stimulating Drugs 



I. Introduction 



There is no class of drugs that is used more often by flying personnel 
than the stimulating drugs. For a few cents, one can obtain, without pres- 
cription, a therapeutic dose of caffeine and other xanthine derivatives, sim- 
ply by buying a cup of coffee, a cup of tea, or a bottle of cola beverage. 
Caffeine is the only drug routinely available in-flight for crew members and 
passengers alike in the larger Air Force aircraft. 

II. CAFFEINE 

1. Pharmacology . What is this drug that is so readily available and 
so plentifully consumed? It is, to quote Goodman and Gillman, "A powerful 
central nervous system stimulant affecting mainly the cortex, the medulla, 
and spinal cord, in that order. " Caffeine is the xanthine of clinical choice 
for combatting central nervous system depressions. It produces a more 
rapid and clearer flow of thought, allays drowsiness and fatigue, and under 
the influence of this drug, one is capable of a more sustained intellectual 
effort and a more perfect association of ideas. There is a keener apprec- 
iation of sensory stimuli, and motor activity is likewise increased. Reac- 
tion time to stimuli usually decreases upon using caffeine, but there may 
be an adverse effect upon recently acquired motor skills in tasks involving 
delicate muscular coordination and accurate timing, such as the firing of 
small arms. All of these effects occur with a dosage of 150 to 250 mgm. 
which is a cup or two of coffee or tea. Even at these dosage levels, there 
is an appreciable blood caffeine level 6 to 12 hours after ingestion. Now the 
usual individual denies that he has experienced stimulation from ingesting 

a caffeine -containing beverage. The reason for this is that the drug action 
is so physiologic that one is usually completely unaware of it. There is 
considerable controversy as to whether or not a mild physiological stimula- 
tion produced by small amounts of caffeine is followed by any "let-down. " 

More to the point, a laboratory test which simulates automobile 
driving has shown that 90 minutes after the administration of caffeine orally, 
a test subject has a very distinct change in his method of driving with hasty 
nervous and restless accelerator pedal operation. There were more errors 
due mainly to hasty reactions. This effect persisted for at least 6 hours. 
So it can be seen that caffeine is not as harmless a drug as is customarily 
thought. 

2. Experience. In spite of all of this evidence, these effects are 
compared with the Air Force experience of what happens when caffeine is 
used. No report could be found in which an aircraft accident or incident 
was attributed as such to the use of caffeine in any quantity. Apparently, 
those who use caffeine have had enough experience to be aware of their 



34 Medical News JLetter, Vol. 32, No. 8 



own tolerances. Certainly, the toxic effects are severe enough to warrant 
occasional warnings and advice to aircrew members. 

in. DEXEDRINE 

1. Pharmacology. A second type of stimulant is the sympathomimetic 
drug group, especially d- amphetamine, or Dexedrine. The results of many 
studies on the effects of this drug upon fatigue are contradictory, mainly 
because of the lack of a common definition of fatigue, how to produce it, 
and how to measure changes in it. In general, it seems that the dimin- 
ished sense of fatigue is subjective and central in origin. Payne and his 
group at the School of Aviation Medicine have shown that Dexedrine prevents 
the onset of fatigue for at least 4 hours in persons performing a complex 
perceptual -motor task, as measured by scores attained and symptoms. 
This effect was not decreased by oxygen impoverishment nor increased by 
oxygen enrichment, hence the sustentative effect of Dexedrine is almost 
wholly derived from its effect upon alertness. 

Dexedrine has one-and-a-half to two times the central stimulation 
potency of the racemic amphetamine sulfate, or Benzedrine, and the pressor 
effects are about equal milligram for milligram. For this reason, when ad- 
vantage is taken of this differential in pharmacological effectiveness, there 
has been much less difficulty with the pressor effects typical of the racemic 
compound, such as various cardiac arrhythmias, headache, light-headedness, 
vasometer disturbances, agitation, confusion, dysphoria, apprehension, de- 
lirium, depression, and fatigue. One of the great worries in the use of 
Dexedrine, however, is still that all of these reactions can occur because 
there is a very wide individual difference in reaction to all drugs of this 
type. Furthermore, one of the more useful effects of central stimulation by 
Dexedrine has been the clinical induction of moderate to severe anorexia in 
obese patients; nutritional status of flying personnel is always of concern 
and the introduction of a potent anorexia drug is not desirable as such. On 
the basis of these considerations, the routine use of any sympathomimetic 
drug by any group of persons is to be condemned. Most of the other sym- 
pathomimetic drugs, such as Benzedrine and Wyamine, possess too potent 
a cardiovascular action to be useful in-flight. 

2. Experience. More experience in the actual use of Dexedrine in 
flying personnel through two main sources is steadily being gained. The 
first source is the group of obese individuals who are striving to meet the 
body weight requirements; many of these persons are taking Dexedrine 
either surreptitiously or with the consent of their flight surgeons. The impor- 
tant thing is that the Dexedrine taken for this purpose, thus far, is not caus- 
ing death and injury — at least as far as is known. A second source of 
clinical material has been the use of this drug in maximum effort missions 
where it has been felt that the hazards of mission-induced fatigue outweighed 



Medical News Letter, Vol. 32, No. 8 35 



those of the drug. There have been published no reports of accidents or 
incidents in-flight directly attributable to the use of Dexedrine within the 
Strategic Air Command. The Aero Medical Safety Division of the Director- 
ate of Flight Safety Research has no record of any accidents attributed to 
stimulating drugs. In fact, that office has a number of accidents wherein 
fatigue was a contributing cause and the use of such a stimulant might have 
prevented the accident. 

Recently, the Tactical Air Command has become involved with the 
problem of long-range fighter operations facilitated by mid-air refuelings. 
The program instituted for such flights has been carefully planned so that 
the pilots receive adequate nourishment and rest the night before flight, 
Dexedrine about 2 to 3 hours after take-off, and at least 48 hours of rest, 
mental relaxation and mild physical exercise after completion of the flight. 
The Dexedrine is given in a 15 mgm. sustained-release capsule, so that 
in-flight "let-down" or depression is avoided. Two hours before landing, 
this is augmented by 5 mgm. more of the Dexedrine, this time in tablet 
form. All individuals using these drugs have been tested for idiosyncracy 
on the ground before in-flight use is prescribed. There have been no un- 
toward reactions to this drug when used in this fashion. The pilots, in fact, 
have been so favorably impressed with this drug that they now insist upon 
its use for this particular type of mission. Some have been found to be 
over- stimulated post-flight and were given one -and -a -half ounces of spir- 
itus frumenti and a few required 100 mgm. of Seconal at bedtime. The use 
of any drug, such as alcohol and the barbiturates, while the subject is still 
under the influence of Dexedrine, is open to question due to the insidious 
changes in judgment and perverse emotional responses which may arise 
with such attempts at sedation. 

A different system of medication is used by the Strategic Air Command 
due to differences in mission requirements. In shorter flights (that is, up 
to 17 hours' duration) a 5 mgm. tablet of Dexedrine is given about 4 hours 
before landing. In flights of longer duration when no rest period is avail- 
able for the crew members, multiple dosage on the same flight is required. 
These doses are spaced so as to avoid the rebound depression; for example, 
there may be a 6-hour interval between the first and second tablets and a 
4-hour interval between the second and third. Again, the flyers are cau- 
tioned about taking any kind of medication and all are pretested for tolerance 
to the drug. 

Therefore, on the basis of Air Force experience with the drug Dexe- 
drine, no reason to condemn its judicious use is found. To the contrary, 
Dexedrine seems to be specifically indicated for specific purposes, such as 
the maximum effort, long duration flight, where fatigue must be avoided 
during frequent and repeated critical intervals of time, such as air refueling. 
It is certain that the use of Dexedrine must be only for specific occasions 
and under the direct supervision and control of the flight surgeon. Whenever 



36 Medical News Letter, Vol. 32, No. 8 



the drug is used, an adequate period of recuperation must be programmed 
and followed. It would seem wise to assure by proper observation the night 
before flight that Dexedrine is not going to be used to overcome the effects 
of other drugs^ especially ethyl alcohol, nicotine, long-acting sedatives, 
and antihistamines. Experience has shown that the use of drugs as a sub- 
stitute for sleep and sobriety has been followed by repeated aircraft acci- 
dents which must be attributed to the unnatural fatigue and intoxication, 
not to the stimulants. It is, therefore, maintained that a highly active 
aircrew effectiveness program in well trained aircrews is the first proced- 
ure to be followed; only after this is in existence can one determine the need 
for stimulating drugs. 

When the capabilities of a well trained and physically fit individual have 
been exceeded by the mission requirements, the ultimate solution lies not in 
drugging the pilot, but rather in revising the machine systems, such as in- 
flight refueling systems, navigation systems, and control systems so that 
human capabilities are not exceeded while the mission is still accomplished. 

IV. Discussion 

All stimulating drugs have the disadvantages of post- stimulation, 
depression, the impairment of needed sleep, other signs of over -stimulation, 
the danger of exhausting physical reserves that otherwise would not have been 
tapped, and finally, habituation and even addiction to the drugs. Side effects, 
such as anorexia, sympathetic nervous system idiosyncrasy, and individual 
variation in toxic thresholds require special attention. It must be conceded 
that there is not a drug in existence which can bring the human organism to 
that level which it reaches by normal training, proper nutrition, and ade- 
quate sleep. On the other hand, it is recognized that there are missions 
which require even more than these basic mechanisms will achieve and 
that as a result stimulating drugs are being used every day in flight. It is, 
therefore, necessary to place a reasonable control over the use of these 
drugs. In the case of the xanthine derivatives, this can be done by adequate 
indoctrination of flying personnel. Absolute control over the use of the 
sympathomimetic drugs must be maintained. This latter group, particularly 
Dexedrine, can be used to advantage in flying personnel for a few highly 
specific purposes, especially in the Strategic Air Command and the Tactical 
Air Command, but careful medical judgment must be mandatory before 
administering such potent drugs. At the present time, it appears that 
stimulating drugs are indicated whenever the risks of in-flight fatigue sur- 
pass the rather limited risks of the drugs themselves. Adequate pre- and 
post-flight management of persons using these drugs is necessary in the 
interest of flying safety and human conservation. The fact that the drug is 
required should automatically indicate the urgent need for further research 
and development of the aircraft systems-. Drugs are to be used only as stop- 
gap aids and not as a permanent solution to a specific problem. 



Medical News Letter, Vol. 32, No. 8 37 



V. Conclusions 

1. The present usages of caffeine are safe. 

2. A complete aircrew effectiveness program is basic and Dexedrine 
is only for essential augmentation of human capabilities. 

3. Dexedrine should be given only when required by the mission with 
adequate pre-, in-, and post-flight aeromedical supervision and control. 

4. The need for a sympathomimetic stimulant indicates the inadequacy 
of the weapons system for the mission. 

VI. Recommendations 

1. The use of Dexedrine in-flight should be permitted, but only under 
complete aeromedical supervision. 

2. An unsatisfactory report upon the weapons system should be man- 
datory before Dexedrine can be used in-flight in that type of aircraft on that 
type of mission. This report should be made by the flight surgeon and should 
contain comments as to what mechanical systems are contributing heavily to 
the fatigue, and suggestions as to improvements. (Captain E. R. Taylor 
(MC) USAF, Toxic Hazards in Military Flying and in the Aviation Industry: 
Symposium, W right- Patterson AFB, 6-7 November 1958) 

$ $ $ $ $ $ 
Partial Pressure Suit Protection 

At the present time, many erroneous conceptions exist in regard to 
the protection afforded by the partial pressure suit. An attempt is made 
here to clarify the capability of the suit and to explain why the over -all 
protection is somewhat limited. 

First of all, some basic facts should be reviewed. The partial pres- 
sure suit was primarily designed to protect the aircrew member against 
his greatest natural enemy — hypoxia. With the development of aircraft 
which can operate above 43,000 feet, hypoxia has developed into a full- 
grown raging monster. The suit, however, has proved itself in this res- 
pect and men have been afforded protection against hypoxia under circum- 
stances in which the total barometric pressure was measured in fractions 
of a millimeter of mercury — for all practical purposes, a vacuum. 

Probably the greatest misconception evident at the present time is 
in regard to the protection which the suit offers against the "bends, " the 
most common type of evolved gas decompression sickness. This miscon- 
ception has probably arisen from the fact that it is common knowledge 
that when the suit is inflated a system of pneumatic levers draws the skin- 
tight suit even tighter, thereby putting a tremendous amount of external 
mechanical pressure upon the surface of the body. Many people have 
assumed that this external mechanical pressure is in effect creating an 
artificial atmosphere on the user's body. They also assume that the 



38 Medical News Letter, Vol. 32, No. 8 



amount of pressure applied to the surface of the body will have the effect 
of "taking the body down to a lower altitude" — 10, 000 feet for instance, 
thereby eliminating the possibility of developing the "bends. " This is not 
the actual true easel 

The external mechanical pressure which is applied to the surface of 
the body is necessary to assist in fighting the basic enemy — hypoxial The 
principle is actually somewhat simple. At extreme altitude, 45, 000 feet 
and above, 100% oxygen under very high pressure must be forced into the 
lungs to prevent hypoxia. The amount of pressure is great enough to 
physically damage the lungs, slow down the blood flowing in the lungs, de- 
crease the ability of the heart to pump blood, and create other disturbances 
of body function. To offset the above disturbances, pressure must be ap- 
plied to the outside of the body to equalize the high internal pressure. The 
skin-tight suit and pneumatic lever system provide this necessary "balanc- 
ing counter-pressure. " Thus, the individual is able to breathe oxygen 
under high pressure and prevent hypoxia without the bodily disturbances 
mentioned previously. 

It is true, however, that some degree of "bends" prevention is pro- 
vided by the external suit pressure, but not to the extent that some individ- 
uals have assumed. The actual facts are: 

The external pressure of the suit gives the same degree of " bends 
protection " at extreme altitude — say 100, 000 feet — that an individual would 
normally have when flying at 40, 000 feet without a suit. Also, it is not 
possible to give the body any greater degree of "bends protection" than that 
which would normally exist between 30, 000 and 40, 000 feet without a suit. 
In other words, with the suit operating at its maximum pressure, it is 
not possible to lower the body physiologically much lower than 30,000 feet. 
This altitude is the threshold for the "bends" — which may or may not develop- 
depending upon many variable factors. 

To clarify the above, the following examples are offered: {Note: The 
breathing pressures given and suit pressures have been scientifically deter- 
mined and are standard. ) 

To prevent hypoxia at 100,000 feet, a breathing pressure of 140 mm. 
of mercury is necessary. An equal amount of pressure must be applied 
to the external surface of the body and this is accomplished by the pneu- 
matic levers (capstans). The individual is now fully protected against 
hypoxia, but what about the degree of "bends protection"? This is easily 
determined as follows: 

Barometric pressure at 100,000 feet, = 0. 31 mm/hg 

External suit pressure at 100,000 feet — 140.00 mm/hg 

Total external pressure at 100,000 feet = 140. 31 mm/hg 
The physiological altitude of the body is now that one where the atmos- 
pheric pressure is 140. 3 mm/hg and in this case is 40, 000 feet. (140. 7 
mm/hg at 40M is actual figure. ) In other words, with the suit fully in- 
flated and at maximum pressure at 100,000 feet, the crew member has 



Medical News Letter, Vol. 32, No. 8 39 

the possibility of developing the "bends" as though he were at 40, 000 
feet without a suit. In an actual case, however, the extremely high rate 
of "ascent" following a decompression in flight would have a tendency to 
speed up the onset of "bends. " 

Now, apply the above procedure to a lower altitude for comparison. 
At a flight altitude of 48, 000 feet, the suit would be needed; to compare 
the "bends protection" possible that figure is used: 

Barometric pressure at 48,000 feet ~ 96.0 mm/hg 

External suit pressure at maximum setting ~ 140. mm/hg 
Total external pressure — 236.0 mm/hg 

Equivalent physiological altitude — 29,000 feet 

It is now evident from the above that, regardless of altitude or suit 
pressure, in regard to the "bends, " the suit can only provide protection 
equal to the normal reaction between 29, 000 and 40, 000 feet without the 
suit. In this example, a maximum suit pressure was used to illustrate 
that the body will still be in the "bends zone" regardless. The actual 
breathing and suit pressure required at 48, 000 feet would give the fol- 
lowing relationship: 

Barometric pressure at 48,000 feet — 96.0 mm/hg 

External suit pressure at 48, 000 feet = 55. mm/hg 

Total external pressure — 151.0 mm/hg 

Equivalent physiological altitude = 38, 500 

In conclusion, the following points deserve further evaluation from 
a combat operational standpoint. It is most likely that the aircraft used 
will have a pressurization system which will keep the cockpit altitude at 
30,000 feet or below which conventional systems are now doing. In turn, 
the suit will probably not be worn in the inflated or emergency state. 
Should a decompression occur, two important questions arise: 

1. Will the pilot be required and expected to complete the mission? 
If so, hypoxia will not be a problem, but the "bends" must be given con- 
sideration. They may or may not develop. If they do arise, there is no 
way to predetermine the severity. They may be mild or barely percep- 
tible or they may be severe and possibly incapacitating. More than 
likely, they will develop to a noticeable degree. 

2. Is a prolonged denitrogenation period necessary prior to a rou- 
tine or combat mission? Prolonged denitrogenation prior to flight has 
proved to be very effective in the prevention of "bends" during altitude 
chamber runs using the suit. However, even with a long period of 
denitrogenation, it is possible to develop a degree of "bends, " but not 
to the extent had no denitrogenation been employed. Should a combat 
operational study of the above be made and denitrogenation adopted as the 
answer, the "way of life" on the flight line will be changed remarkably, 



40 



Medical News Letter, Vol. 32, No, 8 



but isn't it natural to assume such a change when the tremendous 
change occurring in operational aircraft and altitudes is considered? 

(CAPT T. W. Worley USAF (MSC), Air Force Physiological Training Prog- 
ram News Letter, No. 25, September 1956) 

* 4 * * sfc $ 

Policy 

The U. S. Navy Medical News Letter is basically an official Medical 
Department publication inviting the attention of officers of the Medical 
Department of the Regular Navy and Naval Reserve to timely up-to-date 
items of official and professional interest relative to medicine, dentistry, 
and allied sciences. The amount of information used is only that necessary 
to inform adequately officers of the Medical Department of the existence 
and source of such information. The items used are neither intended to be, 
nor are they, susceptible to use by any officer as a substitute for any item 
or article in its original form. All readers of the News Letter are urged 
to obtain the original of those items of particular interest to the individual. 

****** 



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